How to write nursing progress notes

DOCUMENTATION in ELECTRONIC PROGRESS NOTES.

The tool is used to record care required and provided, however any variances from the tool or additional information that does not fit within the tool must be documented in the patient’s progress notes.

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Exceptions: See Special Considerations At the commencement of each shift, following handover, patient introductions and safety checks, a ‘commencement of shift assessment’ is completed as outlined in the Nursing assessment guideline.

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Writing progress notes 10 dos and don'ts Current Psychiatry

The sub-acute clinical areas utilise ‘Record of Patient Care’ care plans which are completed daily (usually on AM shift) and sned off by the nurses on the PM and nht shifts.

Writing <em>progress</em> <em>notes</em> 10 dos and don'ts Current Psychiatry
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An admission assessment is completed and documented on the Nursing Admission (MR850/A) as per Nursing assessment guideline.Purdue OWL APA Formatting and Style Guide


How to write nursing progress notes:

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